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GULF WAR NEWSLETTERINFORMATION FOR VETERANS WHO SERVED IN OPERATIONS DESERT SHIELD AND DESERT STORM AND THEIR FAMILIES

MESSAGE FROM DR. LOREN ERICKSONAs the Director and Chief Consultant for VA’s Post Deployment Health Services and as a Veteran myself, I welcome you to this issue of the yearly Gulf War Newsletter. Inside this issue you will find information about new VA research studies that are currently recruiting across the country, tips on obtaining benefits for Gulf War illnesses or injuries, VA’s effort to create a single case definition for chronic multisymptom illness/ Gulf War illness, and more. This issue is the last issue to be available both in your mailbox and online, so please look for our newsletter online only in the future. More information on how to find this newsletter online is also covered in this issue.

Post Deployment Health Services is a VA-Delivered Foundational Service, meaning its work is fundamental to VA’s mission and is rarely found outside of VA. Our office is committed to producing this newsletter and running a variety of other activities focusing on the health effects of environmental and occupational exposures experienced by deployed Veterans. Post Deployment Health Services conducts research, monitors disease conditions and their relationship to exposures, oversees registry programs (including the Gulf War Registry), recommends policy, and develops educational materials. Learn more about all that VA’s Post Deployment Health Services has to offer at https://www.publichealth.va.gov/exposures/index.asp. Loren Erickson , MD, MPH, DrPH

C&P EVALUATIONS: FOR DISABILITY COMPENSATION, SEE YOUR PROVIDER FOR A HEALTH EXAM FIRSTAccording to scientific publications, between 25% to 33% of Gulf War Veterans will have at least some degree of medically unexplained, chronic symptoms, commonly known as chronic multisymptom illness (CMI) or Gulf War illness (GWI). To be considered for disability compensation for CMI/GWI, Veterans need to have a thorough medical evaluation, get a diagnosis, and have this diagnosis documented in their medical record. This usually requires more than one initial visit to a primary care provider or Compensation and Pension (C&P) clinic.

This is also true for several other diseases presumed to be related to Gulf War service (https://www.publichealth.va.gov/exposures/gulfwar/medically-unexplained-illness.asp).

For example, if the Veteran has been seen by a gastrointestinal (GI) specialist, given an endoscopy, and shown to be diagnosed with irritable bowel syndrome (IBS) in their medical record, then using this information to support a diagnosis of IBS in a C&P clinic could be straight forward. If the Veteran has never been seen by a GI specialist, however, and is describing his or her symptoms for the first time to the C&P clinician, a diagnosis will not be feasible without a more complete work-up. In this case the work-up may require performing the necessary laboratory tests, imaging studies, and procedures to rule out other diseases.

VA recommends that Veterans have a work-up coordinated by their primary care provider and completed before starting the C&P process. A Gulf War Registry health exam before a C&P exam can also help the Veteran identify concerns, although a registry exam is not a disability exam. The registry exam information can be used to support a disability claim, but it is not a substitute for a C&P exam. Having complete records available of all consults, laboratory tests, imaging studies, and other testing or procedures performed, as well as a complete list of all diagnoses made by a primary care provider and/or specialists, helps both the Veteran and the C&P provider in the examination process.

2018

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FILING A CLAIM FOR DISABILITY COMPENSATION VA provides disability compensation to Veterans who are suffering from an injury or illness that occured during active military service. For certain Veterans who served in the Gulf War at any time after August 1, 1990, the illness they experience may be characterized by a wide range of symptoms, such as joint pain, muscle pain, headaches, respiratory issues, fatigue, or weight loss. Sometimes, these symptoms do not match up with recognized categories of disabilities and cannot be diagnosed or explained like most medical conditions that are treated in a clinical setting. VA considers these symptoms as “undiagnosed illnesses,” or in certain cases, “medically unexplained chronic multisymptom illnesses,” such as chronic fatigue syndrome, fibromyalgia, or functional gastrointestinal disorders.

If you are a Veteran who served in the Southwest Asia theater of operations and are experiencing symptoms that you relate to your military service, and you choose to file a claim for disability compensation, here are some important things you should know:

1. Be specific. When filing a claim, you should not merely claim “Gulf War Syndrome” or “Gulf War illness.” This does not provide the level of detail required to process the claim. Instead, provide as many details about the claimed disability as possible to include: a description of the specific symptom(s) you are experiencing, the date each symptom began, how long the symptom(s) have lasted, and all places of treatment for each symptom. VA recommends that you submit the actual medical reports for any and all treatments of your described symptoms. This includes any tests or lab findings.

2. Submit statements from family or friends. Although these statements are not required by VA, they may help to establish the presence of a chronic disability. These witness statements should include information from the section above and any other observations about how the disability is affecting you, both physically and mentally.

3. Attend all examinations that VA orders for each symptom or condition. These examinations are critical for VA to understand your disability pattern. In some cases, VA may need multiple exams and/or diagnostic tests. Be prepared to fully describe each symptom and any past treatments from private physicians.

VA recognizes that Gulf War Veterans may experience signs and symptoms that cannot be attributed to a known clinical diagnosis. VA disability compensation can still be paid for these undiagnosed illnesses or medically unexplained chronic multisymptom illnesses if the condition manifests to a degree of at least 10 percent disabling at any time after service in the Southwest Asia theater of operations. Veterans may file a claim for benefits at www.ebenefits.va.gov or call 1-800-827-1000 for more information and assistance.

Gulf War Service Locations for VA Benefits

For VA benefits, Gulf War Service includes active military duty that

occured any time after August 1, 1990, in Operation Iraqi Freedom (2003-

2010) or Operation New Dawn (2010-2011) in the following locations:

• Iraq• Kuwait• Saudi Arabia• The neutral zone between Iraq

and Saudi Arabia• Bahrain• Qatar• The United Arab Emirates (U.A.E.)• Oman• Gulf of Aden• Gulf of Oman• Waters of the Persian Gulf, the

Arabian Sea, and the Red Sea• The airspace above these

locations

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GULF WAR NEWSLETTER GOING ONLINE ONLY IN 2019

The Gulf War Newsletter is a yearly newsletter for Veterans who served in Operations Desert Shield and Desert Storm and their families. VA has mailed the newsletter to thousands of Veterans each year, and it is also available online. Beginning in 2019, the Gulf War Newsletter will be available online only in order to improve the timeliness of the publication.

Find out when future newsletters will be available online

The best way to find out when future issues of the Gulf War Newsletter are available is to sign up for an email notification. You can find out when the newsletter is released and get other news from VA designed for Gulf War Veterans by visiting https://www.publichealth.va.gov/exposures/gulfwar/index.asp and signing up in the “Get Email Updates” subscription box on the upper right hand side of the web page.

VA also announces the publication of new newsletters on social media. You can follow the Veterans Health Administration (VHA) Facebook page at https://www.facebook.com/VeteransHealth and VHA Twitter at https://twitter.com/VeteransHealth. These resources will keep you up-to-date on a wide variety of health-related news from VA. Breaking announcements, including the release of new newsletters, are also posted on the main VA public health web page at https://www.publichealth.va.gov/.

The online newsletter has a printable PDF format. Each individual article can also be viewed from a newsletter web page.

The latest newsletter can always be found on these pages:

https://www.publichealth.va.gov/exposures/publications/index.asp#gulfwar https://www.publichealth.va.gov/exposures/gulfwar/publications/index.asp

An archive of past newsletters dating back to 1992 is available at: https://www.publichealth.va.gov/exposures/gulfwar/publications/newsletter-archive.asp

This 2018 Gulf War Newsletter is available at: https://www.publichealth.va.gov/exposures/publications/gulf-war/gulf-war-2018/index.asp

There are many online resources to keep you up-to-date on news from VA. 1. VAntage Point, the official blog of the U.S. Department of Veterans Affairs https://www.blogs.va.gov/VAntage/

2. VA YouTube page: https://www.youtube.com/user/DeptVetAffairs

3. VA Public Health Web page https://www.publichealth.va.gov/

4. VA Public Health Web page for Gulf War Veterans https://www.publichealth.va.gov/exposures/gulfwar/index.asp

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VA AND DOD: WORKING TOGETHER TO DEFINE GULF WAR ILLNESSMany Gulf War Veterans have a cluster of medically unexplained, chronic symptoms called Gulf War illness (GWI) or chronic multisymptom illness (CMI). The symptoms can include fatigue, headaches, pain, indigestion, insomnia, dizziness, respiratory disorders, and memory problems. Currently, there is no single validated case definition for CMI, nor is there a diagnostic laboratory test. This has created challenges for Veterans, as well as the Veterans Health Administration and Veterans Benefits Administration (VBA). A single case definition would help clinicians improve the way in which they identify and treat CMI in Veterans, help VBA improve the way CMI claims are handled, and help researchers improve their studies of Gulf War Veterans.

In 2013, the Department of Veterans Affairs (VA) contracted with the National Academy of Medicine to develop a single case definition for use in research settings. The National Academy of Medicine concluded that they could

not develop a case definition because of the limitations of the available data; however, they recommended the two most widely used case definitions for CMI, the Centers for Disease Control and Prevention (CDC) definition and the Kansas definition, be used. The CDC case definition requires a Veteran to have at least two chronic symptoms (longer than six months) from the following categories: pain, fatigue, and mood/cognition. The Kansas case definition requires a Veteran to have at least one chronic symptom in three of the following categories: fatigue/sleep problems, pain symptoms, neurologic/cognitive/mood symptoms, gastrointestinal symptoms, respiratory symptoms, and skin symptoms. The Kansas case definition is stricter, as at least one of the symptoms has to be moderate to severe, and Veterans with certain chronic medical conditions are not considered to have CMI using this definition.

VA is currently working with the Department of Defense (DoD) to create a case definition that can be used both in clinical practice and in research. In the meantime, VA is recommending that

a case definition for CMI developed by a VA/DoD taskforce, called the VA/DoD Clinical Practice Guidelines (CPG) for the Management of Chronic Multisymptom Illness, be used. The CPG definition states: “CMI is a label given to a diverse set of disorders including, but not limited to, chronic fatigue syndrome (CFS), fibromyalgia syndrome (FMS), and irritable bowel syndrome (IBS). CMI encompasses military-specific medically unexplained illnesses, such as GWI, Gulf War Syndrome, or post-deployment syndrome. The definition of CMI also includes patients without accepted labels, defined by generally accepted criteria, who exhibit persistent or frequently recurring symptoms negatively impacting daily function for a minimum of six months’ duration, from two or more of the following six categories: fatigue, mood and cognition, musculoskeletal (including pain), respiratory, gastrointestinal and neurologic (including headache).” VA has implemented a plan to develop, test and validate a data-driven case definition that likely will contain elements of the CDC, Kansas, and CPG definitions.

RESEARCHERS ARE RECRUITING GULF WAR VETERANS FOR HEALTH STUDIES – FIND A STUDY NEAR YOUVA researchers are working to learn more about the health issues of concern for many Gulf War Veterans. They are looking at new ways to diagnose and treat Veterans with Gulf War illness and related conditions. They are also looking at alternative medicine, and trying to better understand how Gulf War Veterans’ bodies function.

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Below is a small sample of current research studies underway across the nation. For a more complete sample of studies, organized by region, visit https://www.publichealth.va.gov/exposures/publications/gulf-war/gulf-war-2018/research-2018.asp. Participating in a research study can not only help you as a Veteran, but can also help Veterans with health issues similar to yours. Find a study near you.

Northeast

Mitochondrial Dysfunction and Gulf War Illness Purpose: To use blood samples to study the part of the body’s cells that help produce energy (called mitochondria) to determine whether cells are damaged, how well they function, and how they correspond to symptoms. Recruiting: Gulf War Veterans and Veterans who were enlisted but not deployed between 1989 and 1994 Recruitment Time Frame: Currently enrolling through fall 2021 Location: War Related Illness and Injury Study Center (WRIISC) in East Orange, NJ Contact: 1-800-248-8005

Southeast

Development of a Simple Blood Test for Diagnosing Gulf War Illness Purpose: To see if/how blood lipid changes could be used to help accurately identify Veterans with Gulf War illness compared to Gulf War Veterans without this illness. Recruiting: Gulf War-deployed Veterans Recruitment time frame: Currently enrolling and ongoing Location: Sarasota, FL Contact: 941-256-8018 ext. 355

Mid-Atlantic

Complementary and Alternative Medicine (CAM) for Sleep, Heath Functioning, and Quality of Life in Veterans with Gulf War Veterans’ Illnesses Purpose: To improve functioning in areas such as pain, fatigue, and concentration through participation in Gulf War health education classes or iRest Yoga® (meditative restoration) and ear acupuncture. Recruiting: Deployed Gulf War Veterans who live in the DC metro area Recruitment time frame: Currently enrolling through 2019 Location: WRIISC in Washington, DC Contact: 202-745-8000 ext. 55768

Texas

A Randomized Clinical Trial of Duloxetine & Pregabalin for the Treatment of Gulf War Illness in Veterans Purpose: To find out if duloxetine and pregabalin, FDA-approved medications for treating fibromyalgia syndrome, can provide relief to Veterans who suffer from Gulf War illness. Recruiting: Gulf War Veterans who live within 100 miles of Waco, TX, and who suffer from chronic pain, difficulty concentrating, unexplained fatigue, persistent headaches, and memory problems. Recruitment time frame: Currently enrolling through 2019 Location: Center of Excellence for Research on Returning War Veterans at the Central Texas Veterans Health Care System, Waco, TX Contact: 254-297-3954 or 254-297-3950.

Multiple locations

Brain Immune Interactions as the Basis of Gulf War Illness: Gulf War Illness Consortium Purpose: To better understand the causes of Gulf War illness symptoms. Recruiting: Veterans with Gulf War illness and healthy Gulf War-era Veterans Recruitment time frame: Currently enrolling and ongoing

Locations: Miami VA Medical Center, Boston University, and Baylor University Contact: 305-575-7000 x6130 or x6706, or email VHAMIAGWI@va.gov

Post–Exertional Malaise in Gulf War Illness: Brain, Automatic and Behavioral Interactions Purpose: To use brain imaging and ultrasound techniques to examine different aspects of a Veteran’s nervous and immune systems and determine how function is affected by exercise. Recruiting: Gulf War Veterans with and without symptoms of Gulf War illness. Recruitment Time Frame: Currently enrolling through fall 2020 Locations: WRIISC in East Orange, NJ, Madison VA Medical Center, and University of Wisconsin-Madison; Veterans from northern Illinois, eastern Minnesota, and northeastern Iowa can also participate. Contact: 1-800-248-8005 (New Jersey) and 608-262-2457 (Wisconsin)

Predictors of Response to Insomnia Treatments for Gulf War Veterans Purpose: To study non-drug treatments for insomnia. Recruiting: Gulf War Veterans who are experiencing sleep problems Locations: VA Palo Alto Health Care System (650-849-0584) in Palo Alto, CA, currently enrolling through 2019.

WRIISC in East Orange, NJ (1-800-248-8005), currently enrolling through winter 2021.

WRIISC in Washington, DC (202-745-8000 ext. 57553 or lucas.crock@va.gov ), currently enrolling through 2019.

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ALL COMPENSATION AND PENSION MEDICAL EXAMINERS NOW TAKING TRAINING ON GULF WAR ILLNESS

To ensure that compensation and pension (C&P) medical examiners are prepared to conduct the Gulf War general medical exam, all examiners are required to take a 90-minute, web-based course on Gulf War illnesses. This training is specifically for clinician examiners and emphasizes the specific details that the Veterans Benefits Administration asks for as a part of the disability rating process.

Clinicians need to take this course to obtain or maintain credentialing to perform compensation and pension exams. All clinician examiners, even those unlikely to directly perform Gulf War-related exams, such as audiologists, are required to take this course. The goal is for all clinicians performing compensation and pension exams to have a better understanding of Gulf War illnesses.

This change is in response to recommendations made by the Government Accountability Office in their report entitled “Gulf War Illness: Improvements Needed for VA to Better Understand, Process, and Communicate Decisions on Claims.”

C&P is distinct from Environmental Health Registry ExamsIn addition to a C&P exam, a different type of exam called an Environmental Health Registry exam is also available to Gulf War Veterans. For benefits, a C&P exam is required. A Gulf War Registry health exam is designed to identify and build a registry of Veterans with service during Operations Desert Shield and Desert Storm that may allow for further studies related to health outcomes for this conflict. It is also designed to help Veterans understand how environmental exposures may impact their health. The findings from this exam are not used in the C&P/claims process.

Some Veterans who participate in the Gulf War Registry health exam may have no medical issues related to their Gulf War service, and some may note problems they associate with their service. All Veterans will receive a follow-up letter explaining the findings from their exam, and a health professional can answer questions about the results. Learn more about the Gulf War Registry health exam at: https://www.publichealth.va.gov/exposures/gulfwar/benefits/registry-exam.asp.